Pharmacy Services
CenCal Health is committed to providing consistent, compassionate, and local support to all CenCal Health providers and members.
CenCal Health’s Pharmacy Team is comprised of Pharmacist and Pharmacy Technician staff. Our Pharmacy Team is ready to assist our provider network and membership with pharmacy-related inquires and education.
Medi-Cal Rx: Medi-Cal Pharmacy Benefit
Effective January 1, 2022, CenCal Health’s Pharmacy benefit called Medi-Cal Rx is administered through DHCS and its vendor, Prime Therapeutics State Government Solutions LLC. Prime provides a comprehensive suite of administrative services as directed by DHCS, which includes claims management/adjudication, prior authorization, utilization management, and customer/support.
Medi-Cal Rx is responsible for administering the following when billed by a pharmacy on a pharmacy claim:
- Covered Outpatient Drugs, including Physician-Administered -Drugs (PADs)
- Medical Supplies
- Enteral Nutritional Products
Additional information regarding Medi-Cal Rx can be found in the “Medi-Cal Rx News” tab below and directly from the DHCS Medi-Cal Rx web site.
For additional assistance contact Medi-Cal Rx Customer Service at: (800) 977-2273
You may also want to visit the Medi-Cal Rx Communication page for any upcoming bulletins and news.
CenCal Health Pharmacy Services: Medical Pharmacy Management
CenCal Health and the Pharmacy Services Team will be responsible for a variety of activities including, but not limited to: oversight of clinical pharmacy adherence, Drug Utilization Review (DUR) and all utilization management associated with pharmacy services (Physician-Administered-Drug) billed on a medical and institutional claim. CenCal Health defines the utilization management of Physician-Administered-Drugs on the medical benefit as Medical Pharmacy Management.
Additional information and education resources for CenCal Health’s Medical Pharmacy Management Program can be found on our Medical Pharmacy Management page.
Respiratory syncytial virus (RSV) is recognized as one of the most common causes of childhood illness and is the most common cause of hospitalization in infants. It causes annual outbreaks of respiratory illnesses in all age groups, and usually starts in the fall and peaks in the winter in most regions in the United States. The CDC recommends RSV vaccination for all adults ages 75 and older and adults ages60-74 who are at increased risk of severe RSV. To protect infants from severe RSV, CDC recommends an RSV vaccine for pregnant people, or a monoclonal antibody given to the baby after birth.
For adults who need an RSV vaccine and have not yet received a dose, RSV vaccine can be administered at any time during the year, but the best time to vaccinate patients is in late summer and early fall before RSV usually starts to spread in the community. RSV vaccine is not an annual vaccine, meaning patients do not need a dose every RSV season. Studies are ongoing to determine whether (and if so, when) revaccination may be needed. There are three RSV vaccines licensed by the U.S. Food and Drug Administration for use in adults ages 60 and older in the United States and they are Arexvy, mResvia, and Abrysvo.
There are two safe and effective immunizations to prevent RSV lower respiratory tract infection in infants. Either a maternal vaccination (Abrysvo) given to mom during pregnancy, or a monoclonal antibody (Beyfortus) given to the baby is recommended, but administration of both is not needed to protect most infants.
Most RSV vaccines are a Medi-Cal benefit and can be covered through the CenCal Health medical benefit or Medi-Cal Rx pharmacy benefit. The exception is Beyfortus which is a covered under the Vaccines for Children (VFC) program and can only be obtained through VFC providers. Medi-Cal will reimburse VFC enrolled providers for VFC funded vaccines when administered for Medi-Cal members 18 years of age and younger for the following three different services:
- Vaccine Administration Fee
- Professional Dispensing Fee
- Pharmacist Services (consultation and assessment [vaccine initiation] fee)
Please reference the Vaccines For Children Program: Medi-Cal Reference Guide for further information.
If you have questions or need additional information, please contact CenCal Health Pharmacy Department at (805) 562-1080.
Medi-Cal Rx Updates:
Changes to GLP-1 Drug Coverage for Wegovy®
Effective April 1, 2026, Wegovy® does not require an approved prior authorization (PA) when prescribed for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH). Claims must be submitted with the appropriate International Classification of Diseases – 10th Revision, Clinical Modification (ICD‑10-CM) diagnosis code(s) (K76.0 and/or K75.8) to be eligible for coverage. Failure to include the appropriate ICD-10-CM diagnosis code(s) will result in the claim denying with Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.
For treatment of other diagnoses, a PA request must be submitted to Medi-Cal Rx for coverage consideration. Wegovy is not covered for weight loss or weight-loss indications.
Prescribers should provide the appropriate ICD-10-CM diagnosis code(s) with the prescription to ensure pharmacy providers have access to the information and document the ICD-10-CM diagnosis code(s) in the member’s electronic health record for auditing purposes.
Reminder: Include ICD-10-CM Diagnosis Codes on Pharmacy Claims
Effective Fall 2026, ICD-10-CM diagnosis code(s) will be required for pharmacy claim adjudication to better implement appropriate UM controls, including prior authorization (PA) requirements. This policy will apply to all pharmacy claims submitted on and after the implementation date, including claims for refills. This will help to ensure and promote clinical appropriateness, essential need, efficacy, member safety, and quality of care. The California Code of Regulations (CCR), Title 22, Section 51502 requires that all billing forms, including both medical and pharmacy claim forms, include, among other key required prescription requirements, “[a] coded description of each diagnosis, in a form prescribed by the Director.” In addition, per CCR, Title 22, Section 51502(d), “the Department may also require additional documentation to determine the medical necessity of services before paying for services under Medi-Cal.”
In recognition of the need for systems coordination, Medi-Cal Rx has initiated a robust education and outreach campaign to support stakeholder understanding and adoption. More detailed information including the implementation plan and resources will be published on the new ICD-10-CM Code Requirements tab on the Education & Outreach page.
Immediate Action Required: Enroll as a Medi-Cal Provider
In alignment with state statute and federal regulations, Medi-Cal will only reimburse prescriptions submitted by prescribers (such as doctors, nurse practitioners, or physician assistants), as well as pharmacists initiating prescriptions under their own scope of practice authority, enrolled as a Medi-Cal provider. Enforcement of this requirement will begin soon, and more specific information will be released once available. To mitigate potential disruptions in Medi-Cal member care and avoid claim denials once enforcement begins, prescribers are required to complete Medi-Cal enrollment with their individual (Type 1) National Provider Identifier (NPI) as soon as possible. Your early action is critical. Complete the following steps to complete your Medi-Cal enrollment today.
Confirm your enrollment as a Medi-Cal provider via the Enrolled Providers list. Once on the page, scroll down to the search field on the right and enter your individual NPI to verify your enrollment status. If enrolled, no further action is required.
If Not Enrolled as a Medi-Cal provider, submit an application using PAVE:
- Navigate to the PAVE Portal and create a profile.
- Once you have created a profile, select Application.
- Fill out the application and ensure all required documentation is attached.
Applications can take up to 90-180 days to be processed. Incomplete or inaccurate application information can delay processing time.
Contact Information
You can call the Medi-Cal Rx Customer Service Center (CSC) at 1-800-977-2273, which is available 24 hours a day, 7 days a week, 365 days per year.
For other questions, email Medi-Cal Rx Education & Outreach at: MediCalRxEducationOutreach@primetherapeutics.com
Medi-Cal Rx Resources and Contracted Drug List (CDL)
Now Available: Medi-Cal Rx Enteral Nutrition Prior Authorization Request
Medi-Cal Rx Searchable Drug Lookup & Contracted Drug List
Medi-Cal Rx Contract Drug List
Find a Pharmacy Search Tool
Medi-Cal Rx Support Services
The following document will provide the processing information for Medi-Cal Rx (i.e. BIN, PCN & Group) and additional payer information.
Medi-Cal Rx Support Services and Key Payer Sheet Details
Pharmacies requesting additional operational claims support please contact:
Medi-Cal Rx Customer Service Center at: (800) 977-2273